Aya Kamaya, M. Edward Lo, M. Clinical Assistant Professor. Mariano, M. Nayeli Morimoto, M. Bhavik Patel, M. Assistant Professor of Radiology. Peter Poullos, M. Luyao Shen, M. Andrew Shon, M.
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Volney Van Dalsem, M. Clinical Professor. Luke Yoon, M. Body Imaging Fellowship. Clinical Instructor Lawrence Chow, M.
Percutaneous Abscess Drainage
Professor of Radiology Terry Desser, M. Professor of Radiology Michael Federle, M. Clinical Instructor R. Clinical Assistant Professor A. Clinical Professor Luke Yoon, M. Interesting cases from the week are presented and discussed. Journal Club is held monthly, with in-depth discussion of the selected journal club article, followed by presentation of clinical cases pertaining to the article.
Ultrasound Conference : At this monthly meeting attended by Body Imaging Fellows, residents, body imaging faculty and ultrasound technologists, Dr. Jeffrey highlights interesting cases, specific topics, or teaching points in ultrasound. Cases presented are typically of a quality and interest level that they are often written up and published in Seminars in Digestive Disease and Sciences Journal. Grand Rounds : Twice a month at this CME-accredited conference, invited guests from around the world, as well as Stanford faculty, present lectures on various topics.
Ultrasound Scanning Club : Once a week, Body Fellows focus on hands-on scanning of a specific anatomic structure with dedicated instruction on proper scanning technique, image optimization, and tips and trick in image acquisition. Didactic Fellow Lectures : This lecture series runs during July through September and is specifically designed for the Body Imaging Fellows, with presentations by the body imaging and cardiovascular faculty. Topics covered include:. In most cases such a process is asymptomatic 6. Thus, gossypibomas represent a feared problem in medicine as, besides the complications to the patient, their impact on the physician-patient relationship and the medical-legal implications 7 are in both cases, very challenging.
The diagnosis of gossypibomas may be extremely challenging for the radiologist because of their variable presentation, usually resulting from the investigation of complaints such as abdominal pain, palpable mass, intestinal obstruction, fistulas, or as part of routine postoperative imaging studies.
In other occasions, the diagnosis results from an incidental finding, years after an abdominal surgery. Eventually, a suspicion may be raised by the clinical team that indicates imaging studies to corroborate the diagnosis of gossypiboma. Main factors involved in the occurrence of abdominal gossypibomas are the following: emergency surgeries, unexpected changes during the surgical act, two or more different teams involved in the surgical act, changes in the nursing team during the course of surgery, patient's obesity and occurrence of intraoperative hemorrhage.
The early identification of such a condition is of most importance, as it results in reduction of morbidity, and may prevent potentially fatal complications, besides mitigating medical-legal complications 4,9. The present essay is aimed at demonstrating a series of typical cases of abdominal gossypibomas and illustrating their different presentations, emphasizing the findings at different imaging methods, by means of conventional radiology, ultrasonography US , computed tomography CT and magnetic resonance imaging MRI , with the purpose of familiarizing radiologists with this disorder and its main differential diagnoses.
Conventional radiology. Radiographs obtained at the surgery room, by means of bedside apparatuses, technical restrictions limiting the images quality therefore, the manipulation and post-processing of the images can be helpful in certain dubious cases. The appropriateness of the field of view in the study must also be considered, as well as the careful evaluation of the periphery of the obtained image, which may include part of a gossypiboma.
The imaging finding of gossypiboma at plain radiography is variable. The most common presentation includes radiodense irregular linear images, some of them serpiginous, associated or not with increase in volume and density of adjacent soft tissues.
In some cases, amorphous radiolucent images are observed, probably caused by gas entrapment or secondary infection by gas-forming germs However, eventually small fragments of surgical material may not include radiodense filaments, so their direct identification by X-ray emitting imaging methods is difficult. Ultrasonography allows the identification of practically all types of gossypibomas, including radiolucent gossypibomas, besides providing information on their anatomical relationships Figure 3A.
Acute Abdomen - Practical approach
Invariably, internal vascular flow is absent at Doppler study Figure 3B Posterior acoustic shadowing is generally present and may be related to the attenuation of the acoustic beam by the foreign body itself, as well as by the presence of gas and, occasionally, by the presence of calcified areas However, US presents some limitations, such as being operator-dependent, besides the possibility of not identifying foreign bodies at greater depths or located posteriorly to gas containing hollow viscus.
Also, it may present false-positive results in cases where scars and calcifications of other etiologies are present. At CT, gossypibomas are generally identified as a mass with well defined contours, with soft tissues density, high or even mixed densities, sometimes containing air bubbles and high density capsule that may presents enhancement in the post-contrast phase Figures 1B , 1C , 3C and 4 10, Sterile gas bubbles may be identified next to the gossypiboma up to six months after surgery However, the presence of gas densities within the gossypiboma should alert the radiologist to the possibility of associated infection Figure 3C.
The CT scout image or scanogram must always be evaluated as many times it holds the key for a correct diagnosis, particularly in those cases where beam hardening artifacts impair the identification of the radiopaque marker on tomographic sections. Gossypibomas should not be confused with a fluid collection, in spite of the possibility of association with the development of abscess.
Multidetector CT MDCT allows reformation of images acquired in different planes, including oblique ones, besides three-dimensional reconstruction, providing the method with extremely high sensitivity and accuracy.
However, the utilization of ionizing radiation and iodinated contrast media constitute limiting factors in this method that should be taken in consideration. The tomographic differentiation between hemostatic absorbable and non-absorbable materials lies in the fact that the latter present a radiopaque marker that is not present in the several absorbable materials. However, the clinical team members interaction and the knowledge on the utilized surgical techniques are determinants of an appropriate interpretation of postoperative images.
Magnetic resonance imaging. Few experimental studies on the utilization of MRI for the detection of gossy-pibomas are found in the literature. Also, there are reports describing cases of patients with retained gossypibomas, submitted to other diagnostic modalities such as plain radiography and CT, in whom only MRI was capable of identifying them, or was utilized as a complementary diagnosis method 10,11,15, Therefore, MRI should be utilized only in those cases where other more easily available imaging methods have not been capable of identifying direct or indirect signs suggestive of gossypibomas, or in those cases where those methods were inconclusive.
The complications associated with each procedure will be in table format consisting of brief text description alongside imaging examples. There will be teaching points - particularly emphasising differentiation between normal post-operative anatomy and complications. Imaging examples will be mostly barium and water contrast studies and CT - but MRI, angiography and ultrasound will also be included.
The book will be divided into nine chapters.
Imaging findings of abdominal gossypibomas
References will be included at the end of each chapter. Line drawings will be illustrated by a consultant radiologist with previous higher specialty surgical training and a consultant surgeon. The editors have collected an extensive library of high resolution TIFF images of post-operative anatomy and complications. All images will have arrows delineating normal anatomy and features of complications.
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